Dr. John FitzGerald
Both processes benefited from Delphi consensus methodologies and systematic literature reviews to inform decision making. However, the two diverge with respect to other aspects of the methodology and presentation, he noted.
"The RAND/UCLA methodology used by ACR resulted in guidelines that were evidence based to be the most efficacious recommendations. As noted, the RAND/UCLA methodology excludes cost of therapy (as typically there are insufficient head-to-head therapeutic cost-efficacy studies on which to base recommendations). The ACR guidelines therefore leave it to the practitioner to use the efficacy-based recommendations, along with their clinical and practical knowledge, to then provide recommendations for specific patients. As an example, allopurinol and febuxostat have relatively similar efficacy but significant cost differences," said Dr. FitzGerald, who co-led the ACR guidelines development project.
"The 3e approach incorporates that next step in decision making to provide evidence-based and practical recommendations to the practitioner," he said.
The ACR effort addressed four specific domains of gout management: treatment of acute gouty attacks, management of urate-lowering therapy, management of chronic tophaceous gout, and prophylaxis of acute gouty attacks. Although the 3e effort focused on 10 specific, clinically relevant questions, it is valuable for other reasons as well, such as the inclusion of diagnosis as part of the recommendations, and the fact that asymptomatic hyperuricemia is addressed, he said, noting that neither of these was addressed by the ACR guidelines.
The 3e recommendations also address the use of benzbromarone, a uricosuric agent that is not available in the United States.
While the 3e effort lacks the extent of detail included in the ACR guidelines, such as the inclusion of specific information on allopurinol dosing, the 3e group is to be commended for the size of the effort, Dr. FitzGerald said, stressing the value of the input from nearly 500 rheumatologists from 14 countries.
Indeed, the extensive effort by "a large group of practicing rheumatologists from many different countries in Europe, South America, and Australasia resulted in the recommendations addressing those aspects [of gout diagnosis and management] that rheumatologists found most clinically relevant," Dr. Sivera said.
She and her colleagues concluded that "the high level of agreement with the final recommendations and the multinational participation increase their utility and will hopefully facilitate their dissemination and implementation worldwide."
The 3e Gout Program was sponsored by AbbVie. Dr. Sivera reported receiving fees from Menarini for preparing educational presentations, and other authors reported receiving lecture or consulting fees and/or research grants from many companies, including AbbVie. Dr. FitzGerald reported receiving honoraria and grant support from the ACR.